Why Relapse Isn't a Sign of Failure

Addiction relapse is common. Studies suggest that approximately half of all individuals who try to get sober return to heavy use, with 70 to 90 percent experiencing at least one mild to moderate slip. In other words, not many people say “I want to get sober,” walk into a treatment center, and never use drugs again.

In this way, addiction is very much akin to other chronic diseases. As with chemical addiction, patients with chronic illnesses such as diabetes, asthma, and hypertension frequently fail to comply with their ongoing treatments—relapsing, if you will, oftentimes with dire consequences. Thus, no matter the chronic disease, it is ultimately up to the individual to adjust his or her lifestyle and assume responsibility for managing his or her own care. Unfortunately, removing the drug (detoxing) is the easy part. Changing the behaviors that compel the addict to use is significantly more difficult.

What Causes Relapse?

Typically, addicts who return to drugs nearly always do so in response to drug-related cues such as seeing drug paraphernalia or visiting places where they’ve scored drugs. These “triggers” are a byproduct of addiction’s two-stage formation process. In the first stage, the reward functions of the brain are hyper-stimulated—taking drugs makes users feel good, which encourages a repeat performance. In the second stage, repeated overstimulation of the reward centers causes long-term changes in how other areas of the brain function, including areas involved with memory, impulsivity, and decision-making.

A helpful analogy is having a flood in your house. You leave the upstairs bathtub running and depart for the weekend. The water overflows and runs into the hall. Like a waterfall it splashes down the stairs and into the living room. When you return, you find that the walls are soaked, mold is forming, and the wood floors are warped and peeling. Your original problem was that the water wasn’t turned off, but now the floor needs to be ripped up and the walls torn out. Turning off the faucet (detoxing) doesn’t undo the damage caused by the water (drugs) to the rest of your house (brain).

In rodent experiments we clearly see this two-stage process. Stage one: Numerous studies show that rats will quickly learn to press a lever that delivers a drug in preference to levers that deliver food or water. The more “rewarding” a drug is, the more furiously the rats will press the bar. We shouldn’t be surprised, then, that when presented with a drug like cocaine rats display behaviors endemic in addiction, foregoing normal activities such as eating and sleeping in favor of getting high.

Stage two: In addition to going crazy for the drug, rats “remember” and “like” the places where they received it. For instance, when cocaine-addicted rats are placed in an environment where they receive only food and water, they accept that no drug is available and they push only the food and water levers. However, when placed back in the cage where cocaine had been available, they immediately engage in a drug-bar-pressing frenzy. They recognize the location and associate it with past drug use. They are triggered by the environment and they become incredibly agitated—they crave—in expectation of the drug reward.

Human addicts react to drugs and develop triggers in much the same way. In fact, modern brain imaging shows that drug use literally alters the connections between the ventral tegmental area (which is part of the reward center) and memory hubs in the brain (such as the hippocampus). Thus, for addicts, triggers to use become hardwired as part of the collateral brain damage of addiction. This is why addicts are highly reactive to cues associated with previous drug use, and also why treatment programs consistently recommend avoiding people, places, and things from the addict’s using past.

The Danger Zone

Study after study shows the first ninety days in recovery are when the greatest percentage of relapses occur. This is because drugs of abuse rewire the brain, and it takes a significant amount of time away from drugs to repair and/or overcome this rewiring. Unfortunately, cravings usually get worse before they get better. In fact, the longer an addict stays clean, the higher his or her response will be to contextual cues. In other words, it’s actually harder to not pick up at sixty days than it is at six days.

Underlying psychological issues such as anxiety and depression are also likely to assert as time away from drugs increases. With proper treatment these symptoms will diminish over time, but from thirty to ninety days sober they hit a peak. On the plus side, after ninety days sober the odds of long-term abstinence increase significantly—a terrific reason to stay in treatment for longer than the currently standard thirty days—and after a year away from drugs the odds of lasting recovery are actually pretty good.

It is incredibly important during initial treatment (and early aftercare) that addicts learn to recognize their triggers because relapse is much harder to prevent when you don’t see it coming. One positive that may actually come from a slip is the addict in question may recognize a new trigger. For instance, the individual may learn that certain music—the tunes he or she plays when using—is slippery. Those songs can then be deleted from the individual’s iPod, phone, and computer. And when they come on the radio, the addict can now see them as a trigger and take contrary action by switching the station, phoning a sponsor, or heading to a meeting. Furthermore, if the addict suddenly has a desire to listen to that music, it is an obvious sign of a deeper issue that needs to be addressed. Understanding this, he or she can actively deal with the deeper problem while at the same time being on guard for other relapse triggers.

The Safety Zone

Interestingly, being in recovery creates triggers the same way using creates triggers. This is one of the many reasons treatment centers want patients to stay longer than thirty days. Repeated attendance in group therapy and 12-step meetings results in cue-induced learning related to recovery. For instance, when an addict hears in group settings, from lots of other addicts, that when they experience a craving to use they immediately call another sober person to ask for help, that individual eventually starts to visualize performing the same action in response to a craving. In so doing, the addict creates a trigger for recovery, and the next time a powerful craving hits he or she will pick up the phone and call a sober friend instead of the local dealer. Thus, triggering cravings in a setting that’s safe and reassuring—a setting in which the person being triggered is unlikely to relapse—dissipates the anxiety and stress caused by the potential relapse trigger. Over time the addict subconsciously dissociates the cue from the past reward of using and associates it with the new reward of sobriety.

Can you please define "mild to moderate" relapse, and indicate the study to which you refer re relapse? How does that data synch up with the more general NIAAA data that shows 70% of alcoholics having but one alcoholic period (mean is four years) in their life, and many of those same folks drinking mildly to moderately thereafter without difficulty.

I completely agree. I don't even use the word, I have officially "retired" it. It takes away from all the work that has been accomplished, and put the focus on what went "wrong" so to speak than what went "right." I think it should be seen as an opportunity to revamp, regroup and to continue.

I completely agree. I don't even use the word, I have officially "retired" it. It takes away from all the work that has been accomplished, and put the focus on what went "wrong" so to speak than what went "right." I think it should be seen as an opportunity to revamp, regroup and to continue.

I work with sex addicts and I'm starting to write a more elaborate description of the sex addiction cycle which includes cues for go ing from one phase of the cycle to the next. I'm also starting to write a specific alternative behaviors (coping mechanisms) for each different phase. Sex addicts, like other addicts, experience relapse as coming "out of the blue". But if they can see relapse as a pre-determined series of steps that lead to relapse, I think it's easier to put the brakes on before the acting out occurs.

Relapse is very common in sex addiction (after all, we take our sexuality with us wherever we go). If the person has a specific "Recovery Plan" in place, relapse is merely an opportunity to discover what needs to be changed in the game plan. I believe the original meaning of the word "sin" is "to miss the mark.

Ms. Hayden, when the NIAAA data talks about so many former alcoholics drinking again mildly to moderately without any ill effects, how can you even have a broad concept like relapse? Is it a relapse if there are no ill effects?

No, there would be no relapse if there were no negative condequences. If someone has set a goal for him/self and that goal was not met, that would be just one in a number of potentially negative consequences.

My point is that if we "catastrophize" each (lapse), the person can get so bogged down in shame and self-loathing that he misses the point of how he could have handled it differently so he has the opportunity to learn from mistakes.
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@ Where the Science Meets the Steps???
AA bashing-- that's the first time I've encountered that. Completely unprofessional of you to dis another recovery program that is working for millions including myself. Smart Recovery, hmmmm... Maybe Rude Recovery is a better name. Oh wait, if there is a fee to use SR, yeah, that's the angle. I get it now.
ToThineOwnSelfBeTrue

I am a layman and I recovered naturally (meaning one day I was passed out drunk and suffering immensely and the next I was sober and of the mindset that I drinking was too bad for me to continue). I don't do any meetings or anything. I was told 2 years was a dangerous date for addicts. I just passed my 3rd year. I find myself occasionally wondering if I will relapse, what horrible things will happen, and how I will address the problem.
At 3 years, statistically, what are odds of me slipping.

You know what else. I love the sea. Both being on it and being in it. I also love Jimmy Buffet music. I associate both with drinking. I can be on the sea and still love it, relate to it. I cannot listen to Jimmy Buffet because I have a feeling it will make me want to drink.

So I guess I know a little about triggers. What do you think statistically speaking about 3 years clean.

I was looking for some help with my food addiction. We use AA materials in our group and this article applies to us too. I recover from compulsive eating by staying away from trigger places, people & food items (and using the 12 steps). I've been clean for 4 years but food smells still trigger me; I walk away, say a prayer, make a call, whatever it takes. Very relevant for me. I know I could relapse, I am not cured, I am in remission.
Thank you for this insight!